[ ] ambulatory clinic.doc

Continuity ClinicAmbulatory Pediatric Outpatient Rotation

CONTINUITY CLINICAMBULATORY PEDIATRIC OUTPATIENT ROTATION

Residents are assigned to one of the following four fivecontinuit outpatient y clinic sites: The Kid’s Place at the Hermann University of Texas Professional Building (“HUTPB”), the LBJ Pediatric Clinic (“LBJ”), The University of Texas Parkview Pediatric Clinic (“Parkview”), and the Northwest Assistance Ministries Pediatric Clinic (“NAM”), and Children’s Protective Services (CPS). Continuity Clinic occurs every morning and afternoon five days a week (M-F) at HPB and five afternoons a week (M-F) at LBJ and Parkview. Continuity Clinic is held once a week on Wednesday afternoon at the NAM clinic.These outpatient clinics are open five days a week. Adherence to the 80-hour work week is mandated.

Medicine-Pediatric residents are often assigned to the Good Neighbor Clinic (“GNC”) as both pediatric and adult patients attend this clinic. Continuity Clinic is held three mornings a week (M, T, and F) and four afternoons a week (M, T, W, F) at Good Neighbor. The Good Neighbor clinic is closed Wednesday mornings and Thursday is used for a teaching day of medical students only.

Residents spend one half-day a week at their respective Continuity Clinic. Residents are only allowed to miss Continuity Clinic if the clinic is closed for a holiday, if the resident is on vacation, or if the resident is post-call. Faculty from The University of Texas Medical School at Houston Division of Community and General Pediatrics supervise the residents in clinic.

Patients seen in these outpatient continuity clinics (Community Clinics) include patients without a previously documented faculty physician from clinics or the emergency room, patients referred to the clinics, managed care patients, and patients requiring follow-up exams from inpatient care at MHCH or LBJ.

Legend for Learning Activities AR – Attending Rounds DPC – Direct Patient CareCAT – Critically Appraised TopicsEBM – Evidence-Based Medicine CourseE/C – Ethics/Communication Conferences

GR – Grand Rounds JC – Journal ClubMR – Morning ReportM&M – Morbidity and Mortality ConferenceMDR – Multidisciplinary Rounds

NC – Noon ConferencesRC – Research ConferenceSS – Senior SeminarSL – Subspecialty Lectures

Legend for Evaluation Methods for ResidentsAE – Attending EvaluationsDSP – Directly Supervised ProceduresMR – Morning ReportPR – Peer ReviewCR – Chart Review

PDR – Program Director’s Review (twice annually)IE – In-Training ExamFS – Faculty Supervision & FeedbackCSR- Chart Stimulated Review


Principal Educational Goals and Objectives by Relevant Competency

The principal educational goals for residents on this rotation are indicated for the relevant ACGME competencies. The tables below each goal list the corresponding educational objectives, the relevant learning activities and the evaluation methods for each objective. The educational goals and objectives are applicable to PGY-1, PGY-2 and PGY-3/4 residents and the expected competency levels demonstrated by the residents should reflect their respective level of experience.

A. Patient Care

GOAL: Manage continuum of care for children seen in the pediatric clinic setting and promote preventive health care for children.

Principal Educational Objectives Learning Activities

EvaluationMethods

1. Develop history and physical examination skills including chart documentation and interviewing.

DPC, FS AE, FS, PDR

2. Review past medical history, family history, immunizations and development.

DPC, FS AE, FS, PDR

3. Assure continuitycontinuity of care when patients are admitted to the Inpatient Unit from the ContinuityCommunity Clinic. Communicate with hospitalists or specialists who provide care for patients admitted or provide care directly to patients admitted from the ContinuityCommunity Clinic.

DPC, FS AE, FS, PDR

4. Function as the primary provider by providing family support and helping with the transitions to and from the inpatient setting.

DPC, FS AE, FS, PDR

5. Develop short-term and long-term plans for patient care and integrate these into case management or continuing care treatment plans. Recognize when it is necessary to update these plans.

DPC, FS AE, FS, PDR

6. Discuss the following preventive health care topics with patients and their families:

DPC, FS, NC AE, FS, PDR

a. Developmental assessments including normal screening.

b. Plot growth curve

c. Discipline and other parenting issues

d. Immunizations – schedule, exceptions, side effects and contraindications

e. Normal and abnormal sexual development of different ages

f. Nutrition – obesity, breast feeding, infant feeding, vitamins and fluoride

g. Screening lab data – lead and anemia

7. Refer patients to appropriate specialists and manage follow-up visits.

DPC, FS AE, FS, PDR


GOAL: Diagnose and manage common signs and symptoms that present to the ContinuityCommunity Clinic.


EvaluationMethods

1. Recognize and manage the following episodic disorders: chronic pain, chicken pox, colic, common intestinal parasites, conjunctivitis, dehydration, diarrhea, fever, influenza, lymphadenopathy, neonatal infections, respiratory tract infections, pharyngitis, thrush, vomiting and persistent cough.

DPC, MR, FS AE, FS, PDR

2. Recognize the following common behavioral problems and counsel parents: abuse, attention deficit disorders, depression, encopresis, eating disorders, enuresis, feeding problems, psychosis, sleeping disturbances, and speech disorders.


3. Recognize and manage allergies including allergic rhinitis and asthma.


4. Recognize and manage common pediatric ear, nose and throat problems including antimicrobial prophylaxis, acute otitis media, chronic otitis, otitis externa, epistaxis (PGY-2), hearing screening (PGY-1), and sinusitis (PGY-2).


5. Recognize and manage common pediatric eye problems including amblyopia (PGY-2), strabismus (PGY-2/3), styes and chalazia (PGY-2), tearing (PGY-2), and vision screening (PGY-1).


6. Recognize and manage common pediatric gastrointestinal problems including chronic abdominal pain, constipation, gastroesophageal reflux, inguinal hernia and hydrocele, hepatomegaly, malabsorption syndrome and pyloric stenosis.


7. Recognize and manage common pediatric genitourinary problems including dysuria and frequency, urinary tract infections and undescended testes.


8. Recognize and manage common pediatric cardiovascular problems including cardiac disease, heart murmurs, hypertension referral and evaluation and SBE prophylaxis.


9. Recognize and manage common pediatric dermatological problems including atopic dermatitis, bacterial skin infections, contact dermatitis, diaper rash, epidermal tumors, hair and nail disorders, insect bites and infections, papulosquamous disorders, psoriasis, seborrheic dermatitis, superficial dermatophyte and yeast infections, vascular nevi, vesicular, bullous and pustular eruption, viral exanthems, and warts and molluscum contagiosum.



10. Recognize and manage vulvovaginitis. DPC, MR, FS AE, FS, PDR

11. Recognize and manage common pediatric musculoskeletal problems including bow legs, knock knees, developmental dysplasia of the hip, flat feet, limping, scoliosis, toeing in and torsional deformities.


12. Recognize and manage common pediatric neurological disorders including craniosynostosis, epilepsy, floppy infant, headaches, microcephaly, macrocephaly


13. Recognize and manage common endocrine problems including diabetes, precocious/delayed puberty, short stature and thyroid disorders.


GOAL: Evaluate and manage common signs and symptoms that present to the ContinuityCommunity Clinic.


EvaluationMethods

1. Evaluate and manage the following common signs and symptoms:


a. General: Health supervision visits, Failure to thrive, weight loss or gain, fatigue, fever, constitutional symptoms, acute life-threatening event (“ALTE”), excessive crying

b. Cardiorespiratory: Hypertension, rhythm disturbance, syncope, heart murmur, shortness of breath, chest pain, cyanosis, dyspnea, tachypnea, wheezing, stridor, inadequate respiratory effort, cough, hemoptysis, respiratory failure

c. Dermatologic: Rashes, pigmentary changes, paleness, petechiae, purpura, ecchymoses, urticaria, edema

d. EENT: Conjunctival injection, acute visual changes, ear, throat, eye pain, edema, epistaxis, foreign body, nasal, ear or eye discharge, hoarseness, stridor

e. Endocrine: Polydipsia, polyuria, heat/cold intolerance, growth disturbance, normal and abnormal timing of pubertal changes

f. GI/Nutrition/Fluids: Abdominal pain, mass or distension, ascites, dehydration, constipation, diarrhea, dysphagia, encopresis, hematemesis, inadequate intake of calories or fluid, jaundice, melena, rectal bleeding regurgitation, vomiting

g. Genitourinary/Renal: Change in urine color, dysuria, edema, enuresis, frequency, hematuria, obstructive uropathy, oliguria, pain referable to the urinary tract, scrotal mass or edema, trauma to urinary tract or external genitalia

h. GYN: Abnormal vaginal bleeding, pelvic or genital pain, vaginal discharge or odor, vulvar trauma or


erythemai. Hematologic/Oncologic: Abnormal bleeding,

bruising, lymphadenopathy, hepatosplenomegaly, masses, pallor

j. Musculoskeletal: Arthritis/arthralgia, bone and soft tissue trauma, limp, limb or joint pain, variations in alignment (i.e., intoeing)

k. Neurologic: Ataxia, change in sensorium, diplopia, headache, head trauma, hearing concerns, gait disturbance, hypotonia, lethargy, seizure, tremor, vertigo, visual disturbance, weakness

l. Psychiatric/Psychosocial: Acute psychosis, anxiety, depression, behavioral concerns, conversion symptoms, child abuse or neglect, hyperactivity, suicide attempt

GOAL: Diagnose and manage common childhood conditions that present to the ContinuityCommunity Clinic.


EvaluationMethods

1. Gather essential and accurate information using problem-focused interview, exam and diagnostic studies.


2. Formulate differential diagnoses with appropriate epidemiologic considerations.


3. Discuss appropriate prioritization of patients and recognize patients with potentially serious problems that require further evaluation, referral or hospital admission.


4. Recognize and manage the following common childhood conditions:


4a. General: Health supervision visits, colic, failure to thrive, fever, overweight, well-child and well adolescent care.

4b. Allergy/Immunology: Allergic rhinitis, asthma, recurrent infections, angioedema, serum sickness, and urticaria

4c. Cardiovascular: Heart murmurs, palpitations, congenital heart disease, myocarditis, cardiomyopathy, congestive heart failure, Kawasaki disease, rheumatic fever, bacterial endocarditis

4d. Dermatology: Abscess, atopic dermatitis, cellulitis acne, superficial skin infections, impetigo, molluscum, tinea infections, viral exanthems, verruca vulgaris, and other common rashes of childhood and adolescence

4e. Endocrine/Metabolic: Hypothyroidism, hyperthyroidism, diabetes mellitus, diabetes insipidis, precocious or delayed puberty, gynecomastia

4f. GI/Nutritional: Constipation, encopresis,


gastroenteritis, foreign body ingestion, gastroesophageal reflux, nutritional issues, hepatitis, appendicitis, pancreatitis, inflammatory bowel disease, and bleeding in stool

4g. GU/Renal: Electrolyte and acid-base disturbances (mild), enuresis, glomerulonephritis, hematuria, Henoch Schonlein purpura, nephrotic syndrome, UTI/pyelonephritis

4h. Gynecologic: Genital trauma, labial adhesions, pelvic inflammatory disease, vaginal discharge or foreign body, STD’s

4i. Hematology/Oncology: Anemia, hemoglobino-pathies, neutropenia, leukocytosis, thrombocytopenia, abdominal and mediastinal mass (initial work-up)

4j. Infectious Disease: Cellulitis, cervical adenitis, pneumonia (viral or bacterial), laryngotracheobronchitis, periorbital and orbital cellulitis, initial evaluation and follow-up of serious deep tissue infections, dental abscess with complications, otitis media, sinusitis, upper respiratory tract infections, viral illness

4k. Musculoskeletal: Apophysitides, fractures, femoral retro- and anteversion, growing pains, limp, metatarsus adductus, sprains, stained Olgood-Shlater, tibial torsion

4l. Pharmacology/Toxicology: Common drug poisoning and overdose, ingestion avoidance

4m. Neurology/Psychiatry: Seizures (evaluation and adjustment of medications), developmental delay, acute neurologic conditions, behavioral concerns

4n. Pulmonary: Asthma exacerbation, bronchiolitis, croup, epiglottitis, pneumonia, sinusitis, tracheitis, viral URI and LRI

4o. Surgery: Initial evaluation of patients requiring urgent referral, pre- and post-op evaluation of surgical patients

GOAL: Develop a logical and appropriate clinical approach to the care of children in the clinical setting.



EvaluationMethods

1. Utilize principles of decision-making and problem solving skills in the care of children in the clinical setting.

DPC, FS AE, FS, PDR

2. Identify and prioritize patients’ medical problems and generate appropriate differential diagnoses.

DPC, FS AE, FS, PDR

3. Use appropriate timing for diagnostic and therapeutic interventions.

DPC, FS AE, FS, PDR

4. Adjust pace to patient acuity and volume. DPC, FS AE, FS, PDR

GOAL: Provide sensitive support to patients and their families in the clinical setting and arrange for on-going support and/or preventive services.


EvaluationMethods

1. Discuss issues such as growth and nutrition, developmental stimulation and schooling with patients and their families.

DPC, FS AE, FS, PDR

2. Recognize problems and/or risk factors in the child or family (e.g., immunizations, social risks, developmental delay) and appropriately intervene or refer.

DPC, FS AE, FS, PDR

3. Document drug allergies. DPC, FS AE, FS, PDR

4. Discuss outpatient management and parent education regarding chronic asthma.

DPC, FS AE, FS, PDR

5. Recognize and respond appropriately to common reactions of family members to recommendations for optimal health supervision and management of common illnesses in children.

DPC, FS AE, FS, PDR

6. Treat families in a non-judgmental, culturally sensitive manner.

DPC, FS AE, FS, PDR


B. Medical Knowledge

GOAL: Develop a differential diagnosis and formulate an appropriate work-up with diagnostic tests to establish a diagnosis for common childhood conditions that present to the ContinuityCommunity Clinic. Develop appropriate treatment plan for the diagnosis.


EvaluationMethods

1. Discuss the pathophysiological basis of the condition or injury.

DPC, MR, FS, NC

AE, FS, PDR

2. Discuss criteria for hospital admission from the outpatient setting.


3. Utilize patient information, current scientific evidence, and clinical problem-solving skills to make informed diagnostic and therapeutic decisions.


GOAL: Demonstrate knowledge and appropriately use common diagnostic tests in the outpatient ContinuityCommunity Clinic setting.


Evaluation Methods

1. Discuss indications for and limitations of standard laboratory tests and imaging studies including principles of sensitivity and specificity.

DPC, FS AE, FS, PDR

2. Demonstrate knowledge of the age-appropriate normal readings of standard laboratory tests and imaging studies.

DPC, FS AE, FS, PDR

3. Interpret abnormalities in the context of specific physiologic derangements.

DPC, FS AE, FS, PDR

4. Discuss therapeutic options for correction of abnormalities when appropriate.

DPC, FS AE, FS, PDR

Laboratory Tests

a. CBC differential, platelet count, RBC indices

b. Blood chemistries – electrolytes, glucose, calcium, magnesium, and phosphate

c. Renal function tests

d. Tests of hepatic function (PT, albumin) and damage (liver enzymes, bilirubin)

e. Serologic tests for infection (e.g., hepatitis, HIV)

f. ESR, CRP

g. Routine screening tests (e.g., neonatal screens, lead)


h. Wet preps and skin scrapings for microscopic examination, including scotch tape test for pinworms

i. Thyroid function tests

j. Culture for bacterial, viral and fungal pathogens, including stool culture

k. Urinalysis

l. Gram stain

m. Developmental and behavioral screening tests (e.g., Connor’s Denver, depression inventory)

Imaging/Radiographic Studies DPC, FS AE, FS, PDR

a. Plain radiographs of the chest, extremities, abdomen, skull and sinuses

b. Other techniques such as CT, MRI, angiography, ultrasound, nuclear scans (interpretation not expected) and contrast studies

Other Testing DPC, FS AE, FS, PDR

a. Appropriately order/use electrocardiogram and echocardiogram

GOAL: Demonstrate understanding of how to utilize physiologic monitoring and special technology in the ContinuityCommunity Clinic setting.


EvaluationMethods

1. Discuss appropriate monitoring techniques for age and clinical setting, describe the indications and limitations of and interpret the results and measurement of the following monitoring modalities: cardiac monitoring, pulse oximetry and repeated assessment of temperature, heart rate, and blood pressure as clinically indicated during an office visit.

DPC, FS AE, FS, PDR

2. Appropriately use the following treatments/techniques in the ContinuityCommunity Clinic setting: universal precautions, hand washing between patients, isolation techniques, administration of nebulized medication, injury, wound or burn care, and oxygen delivery systems.

DPC, FS AE, FS, PDR

3. Discuss normal and abnormal findings at tracheostomy, gastrostomy, or central venous catheter sites and demonstrate appropriate intervention or referral.

DPC, FS AE, FS, PDR


4. Demonstrate the skills for assessing and managing pain and conscious sedation.

DPC, FS AE, FS, PDR

5. Discuss indications for and use of behavioral techniques and supportive care and other non-pharmacologic methods of pain control.

DPC, FS AE, FS, PDR


C. Practice-Based Learning and Improvement

GOAL: Utilize a logical and appropriate clinical approach to the care of children applying principles of evidence-based decision-making and problem solving skills.


EvaluationMethods

1. Develop and apply decision-making and problem solving skills in the care of children.

FS, CAT, EBM, DPC

AE, FS, PDR

2. Demonstrate ability to prioritize care needs: identify urgent issues that require immediate attention, use appropriate timing for diagnostic and therapeutic interventions and adjust pace to acuity and volume.

FS, DPC AE, FS, PDR

3. Assess quality control and quality improvement processes and utilize results to improve patient care practices and patient management in the ContinuityCommunity Clinic setting.

FS, EBM, DPC AE, FS, PDR

4. Discuss how clinical pathways and practice guidelines can be used to improve patient care for patients evaluated and treated in the ContinuityCommunity Clinic setting.

FS, DPC AE, FS, PDR

5. Integrate professional scholarship including electronic and print literature with emphasis on the integration of basic science with clinical medicine into decision-making regarding patient care.

FS, EBM, DPC, CAT

AE, FS, PDR


D. Interpersonal Skills and Communication

GOAL: Participate effectively with other health professionals, specialists and other providers who refer patients both as the primary provider and as the consulting physician.


EvaluationMethods

1. Communicate well and work effectively with fellow residents, attendings, consultants, nurses, ancillary staff and referring physicians.

FS, DPC AE, FS, PDR

2. Develop and demonstrate skills as a team participant and leader in the care of pediatric patients.

FS, DPC AE, FS, PDR

3. Present information concisely and clearly both verbally and in writing on patients to other members of the health care team.

FS, DPC AE, FS, PDR

4. Utilize consultants appropriately and communicate in an effective manner.

FS, DPC AE, FS, PDR

5. Communicate effectively while performing the role of pediatric consultant for hospitalized patients managed by other providers (i.e., family physicians, surgeons, etc.)

FS, DPC AE, FS, PDR

6. Function as the primary care provider in a managed care model requiring PCP involvement in obtaining continuing services from consultants and acquisition of durable medical equipment for children with complex diagnoses or chronic medical conditions.

FS, DPC AE, FS, PDR

GOAL: Develop effective communication relationships with patients and their families.


EvaluationMethods

1. Communicate with families in a developmentally, culturally-sensitive manner that provides families/patient with the information they need to understand the illness/injury, participate in the care, give informed consent, and prevent future injury or dysfunction.

FS, DPC, E/C AE, FS, PDR

2. Effectively listen to the concerns of patients and their families and respond with appropriate information and support.


3. Communicate to a given family and child the impact of each phase of care on the final health care outcome, the psychosocial impact of illness on the child and family, and the financial burden to the family and the



health care system.

GOAL: Maintain accurate, timely, legible and legally appropriate medical records in the ContinuityCommunity Clinic setting.


EvaluationMethods

1. Write notes that clearly document the patient’s progress, relevant investigations and treatment plan.

FS, DPC AE, FS, PDR, CR, CSR

2. Review the patient’s past records for information relevant to current visit.

FS, DPC AE, FS, PDR, CR, CSR

E. Professionalism

GOAL: Provide sensitive support to patients and families of children in the ContinuityCommunity Clinic setting.


EvaluationMethods

1. Treat families in a non-judgmental, culturally sensitive manner.


2. Respond constructively to the “difficult” child and parent and utilize consultant resources as appropriate.


3. Accept professional responsibility as the primary care physician for patients under his/her care.

FS, DPC AE, FS, PDR

4. Partner with parents to develop plans to facilitate optimal health and development for the patient.

FS, DPC AE, FS, PDR

5. Describe the role and beliefs of fathers, mothers, grandparents, other family members and non-family members in understanding physician instructions, making health decisions and implementing management plans.


6. Develop treatment plans that take into account family religious views as they relate to health care choices.


7. Describe the problems of indigent families in seeking acute and preventive medical care for their children including barriers affecting compliance with medical



instructions.

GOAL: Demonstrate commitment to following ethical and professional principles and to ongoing professional development.


EvaluationMethods

1. Demonstrate knowledge of ethical concepts of confidentiality, consent, autonomy and justice.


2. Demonstrate knowledge of professionalism concepts such as integrity, altruism and conflict of interest.


3. Increase self-awareness to identify methods to manage personal and professional sources of stress and burnout.


4. Increase knowledge and awareness of personal risks concerning drug/alcohol abuse for self and colleagues, including referral, treatment and follow-up.


5. Demonstrate initiative in seeking out and participating in continuing education and professional development programs.


GOAL: Practice ethically and within medical-legal constraints in the care of children presenting to the outpatient ContinuityCommunity Clinic.


EvaluationMethods

1. Describe the ethical issues involved with treating pediatric patients including obtaining informed consent for procedures and the judicious use of diagnostic testing and therapeutic modalities.


2. Describe the potential ethical dilemmas that may present in the outpatient ContinuityCommunity Clinic setting including the following:


a. Respect for patient autonomy and confidentiality in the evaluation and treatment of sensitive conditions (i.e., pregnancy, request for contraception and sexually transmitted diseases).


b. Treatment of disabled infants, children and adolescents.


c. Recruiting, enrolling and completing research in pediatric patients.


d. Deciding to accept/decline gifts, meals and CME support from pharmaceutical representatives.



e. Compliance with reporting requirements for infectious diseases, potential child abuse and neglect, or sexual relationships between adolescents and adults.


3. Discuss how to handle situations where one’s own management goals for a patient are in conflict with the family and/or attending physician and when transfer of care is appropriate.


4. Describe measures to be taken to reduce medical malpractice and liability in the outpatient ContinuityCommunity Clinic setting.


5. Describe sources of legal information regarding the following issues: Patient/parent’s right to refuse treatment and the legal options available when parents refuse therapy or leave the ContinuityCommunity Clinic against medical advice; Child and adult abuse/neglect reporting and the referral of abused parents to resources for their protection; and compliance with HIPAA regulations.


F. Systems-Based Practice

GOAL: Interact with other health professionals, specialists and other providers who refer patients to the ContinuityCommunity Clinic both as the primary provider and as the consulting pediatrician.


EvaluationMethods

1. Discuss the role of the pediatric consultant and provide pediatric consultation to primary care providers and specialists in the outpatient ContinuityCommunity Clinic setting.

FS, DPC AE, FS, PDR

2. Describe the role of outpatient and managed care case managers. Work with these case managers to provide optimal health care (PGY-3/4 only).

FS, DPC AE, FS, PDR

3. Function as the primary care provider in a managed care model requiring PCP involvement in obtaining continuing services from consultants and acquisition of durable medical equipment for children with complex diagnoses or chronic medical conditions.

FS, DPC AE, FS, PDR

GOAL: Demonstrate knowledge of key aspects of outpatient health care systems including cost control, billing and reimbursement in the ContinuityCommunity Clinic.


EvaluationMethods


1. Utilize consultants and other resources appropriately. FS, DPC AE, FS, PDR

2. Demonstrate sensitivity to the financial status of patients; utilize resources appropriately for patients/families needing financial assistance.

FS, DPC AE, FS, PDR

3. Describe the common mechanisms of outpatient ContinuityCommunity Clinic cost control in managed care settings, including pre-authorization.

FS, DPC AE, FS, PDR

4. Discuss common billing codes and documentation procedures for the outpatient ContinuityCommunity Clinic.

FS, DPC AE, FS, PDR

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